Individualized nutrition therapy recommended for diabetes, prediabetes

Adults with diabetes should be referred to individualized, diabetes-focused medical nutrition therapy, while overweight or obese adults with prediabetes should be referred to an intensive lifestyle intervention program and/or medical nutritional therapy, according to the consensus report from the American Diabetes Association.

The American Diabetes Association (ADA) recently issued an updated consensus report on nutrition therapy in adults with diabetes or prediabetes, the first time it has addressed the latter condition.

The authors of the report used the ADA's 2014 position statement on nutrition as a starting point and also reviewed evidence published between Jan. 1, 2014, and Feb. 28, 2018. The resulting recommendations are evidence-based but are the expert consensus opinions of the authors. The report was published in the May Diabetes Care.

Areas addressed in the report include the effectiveness of diabetes nutrition therapy; macronutrients; eating patterns; energy balance and weight management; sweeteners; alcohol consumption; micronutrients, herbal supplements, and risk of medication-associated deficiency; medical nutrition therapy and antihyperglycemic medications, including insulin; and the role of nutrition therapy in preventing and managing diabetes complications.

Specific recommendations included the following:

  • The report recommended that adults with type 1 or type 2 diabetes be referred to individualized, diabetes-focused medical nutrition therapy at diagnosis and as needed. Such therapy should be coordinated and aligned with an overall management strategy, including medications and physical activity, the report said. Patients with prediabetes who are overweight or obese should be referred to an intensive lifestyle intervention program, such as the Diabetes Prevention Program, to individualized medical nutritional therapy, or to both.
  • The report noted that while a variety of eating patterns are acceptable for management of diabetes, clinicians should focus on emphasizing nonstarchy vegetables, minimizing added sugars and refined grains, and choosing whole foods over highly processed foods whenever possible. It also recommended that reducing overall carbohydrate intake is a viable approach in some adults with type 2 diabetes who need to reduce antiglycemic medications or whose glycemic targets are not being met.
  • Adults with diabetes or prediabetes who drink alcohol should do so in moderation, and people with diabetes should be educated about signs, symptoms, and self-management of delayed hypoglycemia after alcohol consumption, especially those who are using insulin or insulin secretagogues. Clinicians should emphasize the importance of glucose monitoring after alcohol consumption, the report recommended.

“One of the most commonly asked questions upon receiving a diagnosis of diabetes is ‘What can I eat?’,” the authors wrote. “Despite widespread interest in evidence-based diabetes nutrition therapy interventions, large, well-conducted nutrition trials continue to lag far behind other areas of diabetes research. Unfortunately, national data indicate that most people with diabetes do not receive any nutrition therapy or formal diabetes education.”

The authors recommended several strategies to improve access, clinical outcomes, and cost-effectiveness, including reducing barriers, providing in-person or technology-enabled diabetes nutrition therapy, and engineering solutions to facilitate two-way communication between patients and the health care team. In addition, they wrote, future studies should address how cultural and personal preferences, psychological supports, socioeconomic status, and food insecurity affect care.